surgical history - stritch school of medicine · familial history of ... airway dentition/dental...
TRANSCRIPT
Kurt Baker-Watson, MD
Associate Professor
� Anesthetics
Previous types, complications, satisfaction,
familial history of complications, acute and
chronic pain issues
� Airway
Dentition/dental appliances, temporomandibular
joint (TMJ) disease, pain or focal neurologic
symptoms with cervical motion, snoring,
obstructive sleep apnea, radiation therapy with
subsequent calcification/sclerosis
� Pulmonary
COPD, asthma, recent upper vs. lower
respiratory tract infection, orthopnea
� Cardiovascular
CAD, HTN, angina, MI, palpitations/arrhythmias,
DOE, paroxysmal nocturnal dyspnea, activity
tolerance, PVD, cardiovascular interventions
(PTCA, stents, etc.), CHF, myocardial dysfunction
� GI
GERD and other risks for aspiration, dysphagia,
PUD, hepatic disease
� Endocrine
Thyroid disease, diabetes
� Renal
Renal insufficiency, dialysis (when/type of dialysis
and site of AV fistula if used)
� Musculoskeletal
Rheumatoid/osteoarthritis, DJD of spine,
contractures, myopathies, arthopathies,
positioning preferences
� Neurologic
CVA, paresis, paralysis, seizures, migraines, focal
signs (numbness, paresthesias)
� Hematologic
Bleeding, DVT/PE
Surgical History� Severity of comorbidities
� Repeat procedures– expect longer operation time and higher blood loss
� Tracheostomy/other airway surgery– may require modification of intubation technique
� Smoking
� Alcohol use
� Illicit drug abuse especially cocaine and narcotics
� Medications
Analgesics, sedative/hypnotics, insulin, neurologic/pulmonary/cardiovascular medications, chemotherapy (cardiopulmonary toxicity), anticoagulants/antiplatelet (aspirin O.K.), anti-GERD, herbal supplements
Physical Exam� Assess for airway management and ease of intubation
� Assess for focal signs and severity of disease
� Assess for patient’s ability to tolerate a particular anesthetic or consider delay of surgery for further medical optimization
� Mallampati Classes� I: All
� II: Tonsils and lower half of uvula hidden
� III: Only see soft and hard palate
� IV: Only see hard palate
� Dentition, loose/chipped teeth, dental appliances
� Mouth opening (> 5 cm)
� Thyromental distance
> 6 cm women
> 6.5 cm men
� Prognath
� Cervical range of motion with illicited focal signs (radicular pain, paresthesias, numbness)
� Pulmonary
� Cardiac
� Musculoskeletal
� Neurologic
� NPO except medications for 6-8 hours for particulate food (milk, antacids, baby formula)
� NPO for 2 hours for clear liquids/breast milk
(To establish an empty stomach based on average gastric emptying times)
� Hold particulate antacids (aspiration), diuretics (complicates fluid management), and hypoglycemics
� Modify insulin therapy
� Consider caring for special populations as the starting case (eg. Pediatrics, latex allergy, cirrhosis)
� Age-related lab testing/studies
� Other lab testing/studies as appropriate for comorbidities
� Consultation– for medical optimization
� Physiologic tests (eg. PFT’s, stress test)
-- Establish baseline
-- Assess maximum capacity (physiologic
reserve)
-- Assess responsiveness to therapy
-- Make an intervention and assess response to
therapy
� I: Healthy
� II: Mild to moderate systemic disease medically
controlled
� III: Moderate to severe systemic disease that
affects quality of life
� IV: Same as III with disease posing constant
threat to life
� V: 50 – 50 chance of survival with or without
surgical intervention
� VI: Organ donor
� E: Emergency modifier
� Monitored Anesthesia Care (MAC)/ local with sedation/ “twighlight” anesthesia
� Regional
Neuraxial- spinal, epidural
Plexus block
Nerve block
Infiltration
� General
� Endotracheal intubation, laryngeal mask airway,
mask airway
� MAC/local
� Insufficient analgesia >> recall
� Regional
� Postdural puncture headache > block failure >
bleeding/epidural hematoma, backache, epidural
abscess, neurologic trauma
� General
� Sore throat > nausea and/or vomiting > oral
trauma, aspiration
� I: Sedation
+/- Recall
� II: Excitation
Hypereflexia
Cardiovascular (HTN, tachy)
Motor
Bronchospasm, laryngospasm
Saliv/Urin/Defac/Lacrim(ation)
Divergent gaze
� III: Surgical
5 Goals achieved
� IV: Overdose
Cardiovascular collapse
Clinical Stages of General Anesthesia� Induction
Mask
Intravenous
-- Routine (using nondepolarizing muscle relaxant)
Induction agent– check mask ventilate–relaxant–
ventilate 3-5 minutes– intubate
-- Rapid-sequence (using succinylcholine/SUX)
Induction agent– (mask if Modified)– SUX—
intubate with cricoid pressure (Sellick)
Clinical Stages of General Anesthesia� Maintenance
� Emergence
� Recovery
Return to baseline neurologic status
Control pain (IV, epidural, regional block)
Cardiopulmonary stability
Anesthetic Agents� Volatile agents� Sevoflurane, Desflurane, Isoflurane, (Halothane)� Nitrous oxide� Induction agents
Propofol, etomidate, ketamine, thiopental� Muscle relaxants
Succynlcholine (depolarizing)Pancuronium, vecuronium, atracurium, rocuronium(nondepolarizing)
� Analgesics� Morphine, Fentanyls, NSAIDS� Benzodiazepines
Versed� Local Anesthetics
� I: Amnesia
� II: Analgesia
� III: Anxiolysis-Sedation-Hypnosis
� IV: Muscle relaxation
� V: Reflex control
Medication Amnesia Anxiolysis Analgesia Muscle Relaxation Reflex Control
Volatile Agents X X X X X
Nitrous Oxide X X X
Benzodiazepines X X X
Muscle Relaxants X X
Analgesics X X X X
Induction Agents X X Ketamine Propofol Propofol
Local Anesthetics X X X
� Induction agent
Etomidate (CV stable), Propofol (least N/V)
� Volatile agent
Sevoflurane
� Muscle relaxant
Vecuronium
� Opioid
Fentanyl